Most medical students have some ideas about the specialties and types of practice settings they prefer. Nevertheless, these ideas are often the result of a brief shadowing experience or of a family member who has been a role model. About a quarter of medical students pursue the specialty area they intended to when they started medical school. If you are reading this and are undecided, read on—perhaps a career in orthopaedic surgery is desirable to you. If you have already decided, this chapter will delve into basic elements of a career as a practicing orthopaedic surgeon and will offer descriptions of various specialties within orthopaedic surgery. Either way, consideration should be given to the types of patients, the various pathologies, types of procedures, and spectrum of practice that is appealing to you. Conversely, consider which elements would not be tolerable to you in the long-term. Ultimately, all specialties have some advantages and disadvantages, and all will have aspects that are more or less appealing to you. Career longevity is the result of thoughtful assessment in choosing a specialty and in identifying a suitable practice location and type.

Over the past 20 years, orthopaedic surgery has become increasingly specialized. By 2020, more than 90% of orthopaedic residents were pursuing fellowship training, and only 15% consider themselves to be general orthopaedic surgeons. However, generalists exist in remote areas, where the availability of orthopaedic specialists is not likely, due to smaller populations and larger catchment areas. General orthopaedic surgeons also exist in urban areas, and sometimes, these surgeons are fellowship-trained but perform general orthopaedic services, as well as specialized work in their fellowship area. If you are striving to join existing practices within a specific geographic area, specialty fellowship training may provide a unique market niche for you within that group, even if the specialty itself will not ensure patient material for fulltime practice. Most surgeons, especially when starting out, will take general orthopaedic call (mostly trauma) and may gradually narrow their practice as the surrounding population grows and/or they become a provider for specialty referrals.

Data suggest that spine fellowship provides the highest rate of financial return, while arthroplasty is relatively positive financially, when considering the large number of hours worked it is comparable to general orthopaedic practice. Practices exclusive to sports medicine or trauma have heavy commitments to sports teams and call schedules, respectively, thus are considered negative in financial return. Orthopaedic specialists in hand surgery, foot and ankle surgery, and pediatrics have slightly smaller operative practices on average and may remain negative in financial prospect when compared to general orthopaedic surgery.

In selecting a specialty, the most common reasons are intellectual stimulation and case variety. A strong mentor may also be very influential. Research suggests that financial considerations play a large role for many residents; sadly, basing a career choice purely or primarily on anticipated income is a frequent source of later disappointment.
Be mindful of the big picture as you contemplate these options. What do you really look forward to during your week at work? What are you not going to grow tired or bored of? What types of patients and procedures bring you intrinsic happiness, even when you are exhausted or having a challenging day? These gut feelings may be the strongest inclination as to where you have the best fit and the greatest likelihood of career satisfaction. Among some of the lesser priority considerations in choosing a specialty may be academic opportunities, including research; proportion of outpatient surgery; frequency and complexity of call requirements; altruism; and marketability.

Most residency programs are designed to provide exposure to all orthopaedic specialty areas by your 3rd year of training. Early during your 4th year, you will need to apply for fellowships. This is an evolving process, with more specialties now participating in match procedures. Having a match provides a consistent, fair process, which favors the applicant. When entering the match, your candidacy will be optimized by being extremely organized with your materials, including letters of recommendation. Submitting your package when the site opens up will give you the best chances of receiving interviews at your most desired programs.

Orthopaedic fellowships exist for most subspecialties, including a match process (Table 2.1). Hand and upper extremity surgery has its own fellowship application process, and many programs offer positions to both orthopaedic surgeons and plastic surgeons. Several other orthopaedic specialties have a standardized application process with a match administered via the San Francisco Match program. This includes arthroplasty, foot and ankle surgery, musculoskeletal oncology, pediatric orthopaedics, shoulder and elbow surgery, spine, sports medicine, and trauma. Each specialty has slightly different timelines and other requirements. Although some opportunities exist for fellows to acquire experiences outside of the match, most of the positions are administered and regulated through the match. Some of these, including hand surgery and orthopaedic traumatology, offer a certification based on standardized requirements of fellowship programs.